Home Sleep Test - Clinic Order Form
Thank you for choosing Belun Ring home sleep test.  
Please fill in this order form.  
We will send you the device within 3 working days.
Report will be available within 3 working days from return of device.
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Patient Information
This information will be shown in the test report.
Patient name *
Patient number
As an unique identifier of the patient. Up to 12 letters or numbers.  
Age *
Gender *
Height *
Weight *
Test Start Date *
The device will be sent to your clinic before this date.
Test End Date
The device will be sent back to Belun on this date.
If the device will be delivered to the patient, please provide his/her contact information. 
Patient address
Patient phone number
Clinic Information
Where we will send the device, report and invoice to.
Doctor's Name *
Company Name *
For billing
Contact Person *
Who is handling this test order
Phone Number *
We will contact you by call and WhatsApp
Address of the clinic if you want the device to be delivered there. 
Email *
We will send report and invoice by email.
Please read our privacy policy at https://shop.beluntech.com/policies/privacy-policy. I consent to provide the personal data for the purpose of carrying out the home sleep test. *
For any questions, please contact us at
Email: cs@beluntech.com
Phone: +852-3706-5640
WhatsApp: https://wa.me/85237065640
©2020-2021, Belun Technology Company Limited. All rights reserved.
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